Wounded health systems 

There’s a story of a buddha named Chenrezig who vowed to alleviate all suffering and if he failed, he further vowed to explode into a thousand pieces. This is in fact what happened. Chenrezig worked tirelessly, generating a lot of RVUs, and yet there was even more suffering than when he started. He held true to his vow and burst into a thousand pieces. This story happens daily around the world in hospitals and clinics where dedicated healthcare professionals burn out and burst into a thousand pieces.

It’s not just the work itself that leads to burnout. The annual Medscape Physician Burnout & Depression Report shows that physicians feel that institutional and relational issues contribute to burnout more than patient care. There’s even a movement among physicians to stop talking about individual burnout and instead speak of moral injury as a consequence of institutional factors that interfere with providing compassionate care (a great listen about this is ZDoggMD’s podcast, “It’s not burnout, it’s moral injury”).

Let’s return to the story of Chenrezig, because it doesn’t end with him fragmented into a thousand pieces. An elder buddha, Amitābha, witnessed Chenrezig’s noble vow and subsequent burnout and helped put him back together again. But this isn’t a resilience story where Chenrezig goes back to who he was, but rather he’s transformed, and the thousand pieces become a thousand arms to better touch suffering and a thousand eyes to better see suffering. Chenrezig, through the caring support of an elder, transforms burnout into personal growth and increased capacity to witness and work with suffering. This is what Lucy Houghton and I have been calling “post-burnout growth.”

Could we be missing an opportunity to address burnout? We spend a lot of effort trying to prevent it. As individual health professionals we’re constantly striving to increase our resilience so that we can go back into the hospitals and clinics where we continue to feel re-wounded. Sometimes it seems almost like we treat ourselves like pets—making sure we get enough food, water, and exercise, and that we have a chance to go to the bathroom periodically in our workdays. Is there another way to approach self-care that grows out of nurturance and joy rather than the drudgery of the elliptical or stationary cycle at the gym? Is there a way that we can create cultures of caring rather than self-care being seen as an individual responsibility? As Barton and colleagues write in the “Harvard Business Review, “Rather than focusing on self-care, we need to be better at taking care of each other . . . framing employee distress as a collective rather than individual problem.”

Ways the heart can break

Parker Palmer speaks of two different ways the heart can break: it can shatter into pieces, or it can split open. When the heart shatters, it wounds self and others. When the heart breaks open it grows in compassion and wisdom. It’s this second kind of breaking through in which healers grow, and this is the path of the wounded healer that Chenrezig exemplifies.

Post-burnout growth

While it makes sense to try to prevent burnout, it doesn’t seem to be working well, as studies and surveys report burnout rates of around 50%. In fact, Swensen and Shanafelt write that the “current health care delivery system is perfectly designed to create high rates of professional burnout in physicians, nurses, advanced practice providers, and other health care professionals.” Maybe there’s another way we can approach burnout.

The idea that we can grow from our wounds, from our burnout, is the journey of the wounded healer and what Lucy Houghton and I have been calling post-burnout growth. Analogous to post-traumatic growth, post-burnout growth occurs because of the wound. To grow from burnout, however, we need not only to shift our paradigm, but we also need to distribute caring throughout the systems with in which we work.  As I write in my most recent book:

“The shift from looking at health care worker suffering as an individual deficit (burnout) to an occupational hazard (moral injury) has resonated with many in health care. Rather than looking at only individual self-care, we need institutions that care for staff; rather than only individual resilience, we need organizational transformation into human-centric systems. Whether we call it burnout or moral injury, we need to look at the institutional determinants of physician, clinician, and health care worker health. Our work environments play a role in our health and well-being.”

Caring for self and others

We need to develop models in which caring is the foundation of what we do and how we work—and not just healthcare professionals caring for patients, but a system in which all institutional interactions are founded upon caring—not productivity, evidence-based protocols, or business management models, but on caring, from top to bottom of the institution.

Caring can be taught. My friend Tulika Singh and I teach a Veterans Affairs (VA) Whole Health course called Taking Time to Care. Another friend of mine, Greg Serpa, has developed the HEART course (Hospital Employee Awareness and Resiliency Training). Outside of the VA, Makransky and Condon have developed Sustainable Compassion Training, as another example, growing out of the Tibetan Buddhist tradition of Loving Kindness. And I’ve developed the caring for self & others program of 10 different individual and institutional dimensions of caring where I talk about the need to develop “CHE”—Continuing Human Education, similar to our existing CME (Continuing Medical Education). We could even develop CCE—Caring & Compassion Education, where everyone from support staff, to professionals, to leadership sits down together and learn and practice caring for each other.

Implementation considerations:

1. 10% of CME shifted to “CHE.”

This could include some personal practices of yoga, meditation, tai chi, et cetera, as well as an evidence-based review of these different self-care practices and resources for staff and patients. This could also include formal certification for staff for teaching meditation, yoga, et cetera, for staff and patient wellness.

2. Formal mentorship programs.

Each new staff member is paired with a senior staff member and has protected time to meet monthly or quarterly.

3. Weekly or monthly peer support programs. 

This peer supervision was a requirement for certification when I worked in New Zealand. I’ve seen it implemented as protected time, and this could focus not just on clinical competency, but on emotional processing and peer support.

4. Annual caring and compassion training programs.

As I have developed in Caring for Self & Others and the other programs mentioned above.

5. Support programs for when—not if—staff burn out. 

For instance, a yearly CHE program that focuses on support, caring, emotional processing, building community, personal development in caring for self strategies, and continuous performance improvement feedback for the institution.

6. Availability of healthy food and drink in clinical areas.

If there’s so much work that people feel they must work through their lunchtime—feed them! Food is the most basic way to nurture and care for someone. Studies show that well-fed staff perform better clinically and that staff wellness can affect patient care, for instance Lemaire et al, “Physician nutrition and cognition during work hours: effect of a nutrition based intervention.”

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.